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The Business Side of Health Care: Medicare and Medicaid Creating New Careers

Who is it who forges our nationís health care policy? There are a lot of players. Itís not just health care organizations that set the standards, and itís not just state boards that determine what qualifications a person needs to practice. Payers also have a hand in shaping legislation. The single biggest payer is the national government. Medicare and Medicaid together provide services for 100 million: seniors, children, low-income individuals, and people of all ages who suffer from kidney failure and other diseases or disabilities. Itís not surprising, then, that these organizations are vested in setting standards. From licensing to patient documentation, the Centers for Medicare and Medicaid Services are big stakeholders, and itís likely they will continue to be in the years and decades to come.

Health Care Licensing and Service Reimbursement

In recent years, there has been a trend toward increased credentialing of health professions, including those that require lower levels of education. Medicare serves a disproportionate number of people who require hemodialysis and/ or assistance with daily living. Those who provide care at nursing homes or kidney dialysis centers need to be certified or licensed.

Some health care managers gain their experience outside the health industry; degrees are often in business administration. In most settings, managers are not required to hold a state license. Those who oversee operations in nursing homes, however, are. From direct care workers to managers, long term care workers are a credentialed bunch.

A health care professionalís credentialing determines not just whether services can be billed, but at what rate. A nurse practitioner, for instance, can expect that procedures will be covered by Medicare at 85% the rate they would be if a primary care physician were performing the same service.

Health Care Documentation

Centers for Medicare & Medicaid Services (CMS) rules and regulations are extensive, and attempt to cover all contingencies. They state, for example, that a Medicare patient may get a second opinion from another provider if she has been told that surgery is necessary. Both providers can expect to receive payment. In cases where services are provided concurrently by two different doctors with essentially the same specialty, though, the person documenting will need to demonstrate that all services were medically necessary Ė and that the second wasnít just a case of the family doctor stopping by the hospital ward to offer some encouragement.

This is but one example. Medical documentation can be a headache for doctors, nurses, and other providers; they would rather be researching or spending time with patients. These regulations, though, are creating new jobs. AHIMA, the leader in health information credentialing, will soon offer a new certification. This is for health information professionals who are experts in (among other things) Medicareís Recovery Audit Contractor program.

Despite the increased need for health information professionals, the field can be a hard one to crack Ė at least for those with no health care experience. Itís easier if you know the health care world and have filled out a chart or two in your time or completed a billing and or coding program or a health informatics program.

CMS and Preventive Care

Medicare is among the organizations seeing some shift in focus from crisis management to preventive care. In 2011, Medicare recipients became eligible for free annual wellness checkups. Seniors can now get free mammograms and certain other types of cancer screening; they can also have their cholesterol and bone density measured. It is expected that these policy changes will cause shifts in the health care market Ė and improve the quality of care.

Health Care Providers Shaping Health Care

CMS is certainly influential. Health care workers should remember that the influence extends in both directions. From AHIMA to the AMA, health care organizations frequently provide feedback to lawmakers about legislation. As a member of one of these organizations, youíll have a voice when it comes to those issues that affect you. Once you choose your path in this area and join a professional organization like AHIMA or the AMA, you may find yourself involved in changing policy at the highest of levels.